VICENTE SOTTO MEMORIAL MEDICAL CENTER

Center for Behavioral Sciences

Department of Psychiatry

“PUYA”

A case report on
Bipolar Disorder Type I with Psychotic Features

Submitted by:

CEBU INSTITUTE OF MEDICINE

CEBU DOCTORS’ UNIVERSITY
1. Angtud, Kim Harold
COLLEGE OF MEDICINE MATIAS H. AZNAR MEMORIAL
2. Chua, Catherine
1. Ganas, Catherine COLLEGE OF MEDICINE
3. Lastimoso, Rona
2. Garces, Jiro 1. Bagolbol, Vaniza
4. Nicolas, Shiela Cres
3. Go, Vincent John 2. Chaudary, Piyusha
5. Salomon, James Annjo
4. Larrazabal, Angela 3. Diaz, Cherry Leeh
6. Tan, Alexandra Monica
5. Perino, Daniel 4. Dumanon, Diola Joy
6. Razo, Krissa 5. Gonzaga, Diane
7. Vattikuti, Bhavana 6. Minorca, Alexandra
7. Saladero, Edward
8. Pasal, Mark Justin
9. Trivedi, Keyur

UNIVERSITY OF THE VISAYAS-GULLAS

COLLEGE OF MEDICINE XAVIER UNIVERSITY-DR. JOSE P. RIZAL
SCHOOL OF MEDICINE
1. Belocura, Judd Derick
2. Intikood, Katawut 1. Arengo, Alyanna Mae C.
3. Escobar, Eron 2. Diocampo, Nikki J.
4. Rayapati, Tulasi 3. Hadji Salic, Abrar D.
5. Vasnani, Deepika 4. Okit, Kristine R.

Submitted on:
August 15, 2018

Submitted to:
VSMMC Department of Psychiatry

Resident In-Charge:
Euriz A. Calmerin, MD

TABLE OF CONTENTS
ACKNOWLEDGEMENT
 OBJECTIVES

General Objective:

To discuss the case of patient EM, a 27 year old, female, married, Jehovah’s Witness, housewife
residing at Ticad, Bantayan Island, Cebu.
Specific Objectives:

1. To present a case of Bipolar Disorder Type I with Psychotic Features;

2. To be able to present the biopsychosocial formulation of the patient’s history, and mental status
examination;
3. To discuss the epidemiology, risk factors, clinical presentation, DSM V diagnostic criteria, course
and prognosis of Bipolar Disorder Type I;
4. To be able to present the differential diagnoses for the case presented;
5. To be able to discuss the course of treatment and prognosis of the patient.

I. General Data
Informant and Reliability: Patient, Sister

Patient EM, a 27 year old, female, married, Jehovah’s Witness, housewife residing at Ticad, Bantayan
Island, Cebu came in for the first time at VSMMC CBS last August 7, 2018.

Chief Complaint:
“Ambot ngano naa ko diri. Gipa-anhi rako nila para mu kalma” as verbalized by the patient. “Sige man
gud ni siya manghasi sa balay, dapatan ug sumbag-sumbagon niya iyang bana. Dili pud siya matulog” as
verbalized by the patient’s sister.

History of Present Illness

One year prior to consult, patient was noted to isolate herself from the crowd, preferring to stay indoors,
becoming irritable whenever there are guests in their house, avoiding other people and at times seen
staring blankly. The patient’s sister claimed that she only noticed these behavioral changes 5 months
after the patient gave birth to her 4th child. Patient’s older sister remembers her to have a happy
disposition - talkative, having a jolly demeanor. According to her, the husband noticed that the patient had
become fond of reading the bible and sometimes read it out loud. He also said that the patient was
sometimes paranoid, telling him that she hears a man’s voice telling her, “naay mupatay nako”, as
verbalized by the patient. There was also an instance when the patient pointed at a calendar and said,
“naay petsa na mamatay nako.” The patient’s sister also noticed the patient talking to herself, “mag-
english English na siya kalit, mangadyi unya kung makakita namo magsturya sturya muapil jud na siya
unya magtuo siya na gilibak kuno namo or siya ang giisturyahan” as verbalized by the patient’s sister.
They also noticed that the patient would shift from one task to another without completing the previous
one. At one time, the patient was seen by herself in the hammock. When her sister approached her, she
was muttering “kakapoy na sigeg panganak”. The patient’s sister noticed that the patient no longer
engaged in conversations unlike before. No consult or intervention was done.
In the interim, the sister claimed that the patient’s unusual behavior persisted. She however mentioned
that she only has a vague idea about the patient’s progression of behavioral changes because her sister
is residing on another island and would only receive calls from the patient’s husband. Her sister also
claimed that the patient would skip meals and lacked the initiative to feed her children. There was also a
decrease in self-awareness as to appearance and hygiene, as claimed. She was accused by the patient
to be her husband’s mistress. Her sister also mentioned that the patient did not sleep, verbalizing that,
“dili jud na siya matulog. Maglingkod ra na siya, magtanga. Usahay mamukaw na siya sa mga matulog,
pero dili jud na siya matulog. Inig buntag, kapoy na na siya, pero di gihapon katulog.” When asked what
the patient usually does at home, sister stated that patient would just sit or watch TV. She no longer
cleans the house, bathes her children, brings them to school or cooks. However, when asked if patient
takes a bath regularly, the patient said, “O, maligo jud ko taga buntag. Naligo gani ko gabii.” The
symptoms still persisted prompting the family to seek consult at a traditional faith healer initially then to
the municipal health officer, “nagpa-bisaya mi una pero wala man gihapon epekto mao na niadto mi ug
doktor sa munisipyo unya gi tagaan ra siya tambal pangkatug, wala rapud ni ingon ang doktor kung na
unsa siya pero kato nitumar siya sa tambal makatugon pud hinuon siya.” Patient was given take-home
medications, name unrecalled, with no relief of symptoms, as claimed.
One month prior to consult, patient started becoming violent, punching her husband, accusing him of
seeing other women. When asked why, she replied, “Kay feeling nako di ko importante unya magselos ko
kay naa jud koy kutob na naa siya’y lain. Kalit ra mawala sa balay unya dili ko atubangon kung naa ko
isturya niya.” Patient then gave birth to her fifth child, planned, as claimed by the couple. A few weeks
later, patient was noted to be crying frequently. Her sister noted that the patient would cradle the infant in
her arms but would not feed her. “Kung muhilak ang bata, mu-hilak sad siya og apil. Dili man niya pakan-
on murag makalimot siya.” as verbalized by the patient’s sister. Patient continued having poor appetite,
eating only when spoonfed. Persistence of patient’s symptoms caused a strain in her relationship with her
family, as claimed.

Five days prior to consult, patient’s sister took the patient’s newborn from her due to her inability to look
after her children, saying, “Maluoy man gud mi sa bata, dili ma-atiman. Makalimtan niya ug pakaon.” This
caused agitation and upset on the patient’s part, demanding them to return her baby to her care.

Night prior to consult, patient’s sister was staying over at the patient’s house. Patient started hitting her
husband when she woke up without him beside her. “Iya ra gi-pugngan ug gi-gakos pero gi sipa sipa
gihapon siya unya sige ug ingon na nakig-kita daw siya og babaye sa gawas.” as verbalized by the
patient’s sister. She tried to intervene but instead got hit by the patient. “Nagisi gud akong tshirt unya nag-
ingon ingon siya na kabit daw ko kay ngano daw gi-depensahan nako iya bana. Mao na ana ko ngano
mangabit man ko na minyo naman ko.” This was the first time the sister witnessed the patient hit her
husband, thus decided to seek consult at VSMMC-CBS.

Past Psychiatric and Past Medical History:

Patient had no prior psychiatric consult done. No known psychiatric history. Patient has no suicidal or
homicidal ideations, she also said, “kay naa man ko mga anak.” Patient is not a known hypertensive,
diabetic or asthmatic. Patient has no known food and drug allergies. Previous surgery when she was 4
years old on her right hand following a swimming incident, one prior hospitalization, year and reason for
admission unrecalled.

Substance Use/Abuse

Patient is a non-smoker, non-alcoholic beverage drinker and denies any history of illicit drug use such as
marijuana and methamphetamine.

Family History:

Patient has no known family history of psychiatric illnesses. When she was ten years old, her
mother died due to a motor vehicular accident, alongside with her younger sibling. The patient’s
father, a fisherman, became an alcoholic after the incident, becoming violent towards his
children. He now has a new family and no longer

Patient’s sister claims not to have any psychiatric illness noted within the family. Patient’s
mother died when she was ten years old due to an accident involving a truck and it’s cargo
falling on them as the patient’s sister vaguely recalls. The father, who works as a fisherman, no
longer maintained close ties with them as he now has his own family. But sister recalls him to be
greatly affected by his wife’s death to the point that he became an alcoholic, returning home
drunk and getting aggressive with them with instances wherein he would hit them. Patient and
sister no longer have any contact or form of communication with their father. Patient has 7
siblings but only 3 remain. The first 2 siblings as recalled by the sister died because “ Gi kuha
man daw toh sila ug enkanto.” Followed by the accompanying sister, and then the patient who is
the fourth child. The fifth sibling died during her early childhood allegedly due to ‘convulsions’ as
the sister claims. The sixth sibling died alongside their mother in the accident. And the youngest
sibling remains in Bantayan as a housewife. Due to the death of their mother the remaining
three siblings were separated, distributed among relatives. At ten years old the patient was
taken under the care of their ‘tiya’ along with her younger sibling while the older sister was put
under the care of their grandmother living in another island. Both guardians were reportedly kind
as claimed by the sister but she did not have any knowledge as to how the patient was treated
during their separation. They were not able to have constant communication and would remain
separated for years until adulthood without knowing the condition of each other. Patient has no
knowledge of any heredofamilial diseases.

Gynecologic and Obstetric History

Menarche was at 11 years old, with regular cycles, lasting about 7 days, uses 3 fully soaked cloths used
as sanitary pads, with no associated dysmenorrhea. Coitarche was at 14 years old. No history of
contraceptive use. No history of STIs. She is a G6P5(5015).

Pregnancy Outcome Year Place Term Sex Complications Present

Order Status

G1 Abortion 2008 -- -- -- -- --

G2 NSD 2009 Birthing Term M none alive

home

G3 NSD 2010 Birthing Term F none alive

home

G4 NSD 2014 Birthing Term F none alive

home

G5 NSD 2016 Birthing Term F none alive

home

G6 NSD 2018 Birthing Term M none alive

home

Personal and Social History:

Patient claims not to have any knowledge of her parents’ age when they were pregnant with her
nor if she was a planned or normal pregnancy. When asked about her childhood development
patient would reply “Ambot basta okay raman ko.” Sister claims that developmental milestones
were at par with age. No learning or hearing disabilities were noted. Patient was only able to
reach Grade 4 but stopped after the death of her mother, she was greatly affected because they
had a very close relationship. She lost interest in going to school in the process yet does not
express any regret in doing so. Patient’s sister does not have any knowledge of the patient’s
history of any physical or sexual abuse. In adolescence, patient was allegedly a very talkative,
hardworking, generous and happy person as the sister recalls. She had her first sexual
relationship at 14 y.o. Patient now is a 27 y.o married housewife who previously worked as a
“labandera”. Husband works as a ‘trisikad’ driver or delivery and provides the financial aspect of
the family. Patient claims they had neither problem in terms of money nor scarcity of food. She
also stated when asked, that husband would take part in caring for their children and was not
negligent in his duties as a father. Sister claims that husband was not abusive to the patient and
that he would not fight back whenever the patient would attack him. He would hug the patient or
try to calm her down during these events. Patient has 5 children and only the eldest child was
planned. She also had 1 history of miscarriage. Sister claims it was before her 5 current children
were born. That event affected the patient greatly wherein she was noted to be “mag luya”,
having a hard time moving on but resolved when their eldest child was born. Patient lives in a
one story house made out of bamboo near the sea. The family sleeps on the floor and does not
have a CR. Patient would just wrap any bodily waste in plastic and throw it away. Water source
was the local municipality’s tank. Family would bathe just outside their front door using a bucket.
Good electricity. House was noted to be located in an isolated area surrounded by soil and
greenery.

Sexual History:

Patient is a heterosexual female who had her first sexual intercourse at 14 y.o. with a live-in
partner. The patient would reply “ambot niya.” when she was asked how old he was when they
started living together. Patient’s sister had no knowledge as to how she was treated under his
care but recalls “ buotan man daw toh siya pero kawatan lang. Mag cge ug inom. Mao na
nagbulag ra sila kay mag cge man pangayu ug kwarta.” She did not know if the patient
experienced any form of abuse during their one year of living together. Her second partner is
her current husband whom she had been with since she was sixteen y.o and got married 1-2
years after as the sister claims.

Mental Status Examination

Patient was examined conscious, sleepy, agitated, and uncooperative wearing a stained purple shirt and
floral pants. She was poorly groomed with unkempt hair and musty odor. She had a soft and low voice
with clear speech and slow rate. She was agitated and kept on demanding to go back home to her
children, with episodes of crying and stomping during the interview and attempted to go out of the
building. She had an appropriate affect. She was easily distracted but poorly followed commands. She
was unable to maintain eye contact and often times (looks where?). She had no tics and mannerisms.
She denied any hallucinations and suicidal and homicidal thoughts. She is oriented to time, place and
person. She has poor concentration. When asked (concentration question), she replied with (insert
patient’s cheka) and comprehension. Patient refused to be tested with immediate memory or simple
problems. When asked (insert question), she responded with (insert cheka claiming why she had to
take an exam when there was nothing wrong with her). In the course of the interview, patient became
upset in the process and refused to cooperate. She has intact remote and recent memory. She has both
poor insight (insert specific) and judgment. When asked what she would do in a situation wherein her
baby accidentally fell while she was holding him, wounding his head with apparent bleeding patient
replied “ Aw kung ing.ana nga mahulog wa gyud na nako tuyu.a. Ako siya puniton unya butangan nako
ug ice iyang ulo.” When asked further if she would consider bringing the infant to the hospital she replied,
“ Aw depende. kung nay kwarta.” When interviewer insisted that the baby was clearly dying and in pain
patient responded “ Depende gihapun” Patient refused to take medication insisting to go home.
(still for edit)

Physical Examination

The patient was examined conscious, sleepy, ambulatory, and not in respiratory distress with vital signs
as follows: BP 110/70 mmHg, PR 88, RR 18, Temp 36.3’C and anthropometrics as follows: Ht: 5’1” Wt
65kg BMI of 27.

Skin: Brown, warm to touch, good turgor, with no note of rashes

HEENT: Anicteric sclerae with slightly pale palpebral conjunctiva, nasal septum at midline, no naso-aural
discharges, no tragal tenderness, moist lips and mucosa with no ulcerations

Neck/ Lymph Nodes: Supple neck, no lymphadenopathies, no neck vein distention, trachea at midline,
no neck masses

Chest and Lungs: Equal chest expansion, clear breath sounds, equal tactile fremitus, resonant on
percussion

Breast: Not done

Cardiovascular: Adynamic precordium, distinct heart sounds with normal rate and rhythm, PMI at 5th
ICS, no murmurs, heaves or thrills

Abdomen: Soft, normoactive bowel sounds, non-tender

Rectum: Not done

Urogenital System: Grossly female, negative kidney punch sign

Extremities: CRT <2 seconds, full pulses, no edema

Neuroexam: GCS 15, 5/5 motor strength on all extremities, able to smell, intact EOMS, 2/2 ERTL, intact
facial sensory, no facial asymmetry, able to hear on both ears equally,

CLINICAL FORMULATION

Primary Impression: Bipolar I with Psychotic Features

This disease was primarily considered since the patient has symptoms for Manic Episode according

to the DSM-5 Diagnostic criteria and had psychotic instances a year prior to her admission. Patient’s

symptoms was noted a year ago wherein she was noted to prefer to isolate herself wherein also she

verbalized that she had auditory hallucinations about her death in which she became paranoid about it.

Patient was also noted to talk spontaneously about random things and also noted to be talking to herself

more than the usual. Patient was also noted to be easily distracted as she starts a random task without

finishing it. Patient was also noted to be in irritable mood that she’s not welcoming anymore whenever a

visitor came to their house as compared to her previous personality and also she constantly thinks of her
husband having a mistress and became aggressive/hostile against her husband. Patient was also

observed to have a decreased in sleeping time and decreased in appetite. Patient started to don’t do her

responsibilities as a mother. Patient then was noted to be in depressed mood as she was observed to be

crying more than the usual a month prior to admission. Patient was then noted to be in

aggressive/irritable mood five days prior to admission and a night prior to the admission as she was

observed to attack her husband thinking that her husband had a mistress which is not true as claimed by

the patient’s SO. Patient denies of any smoking, alcohol drinking and illicit drug use. Patient denies of any

underlying medical illness, is non-diabetic, non-hypertensive and has no maintenance medications.

During the interview and mental status examination, patient’s mood was variable as she was noted

to be agitated and demanded to go home, and had crying episodes. She was also noted to be easily

distracted, also has a brief eye contact when spoken to, poor comprehension, concentration, insight and

judgment, and became uncooperative as the interview progressed.

DSM-5 DIAGNOSTIC CRITERIA FOR MANIC EPISODE RULE RULE

IN OUT

A. A distinct period of abnormally and persistently elevated, expansive or ✔

irritable mood and abnormally and persistently increased goal activity or

energy, lasting at least 1 week and present most of the day, nearly every day

(or any duration if hospitalization is necessary).

B. During the period of mood disturbance and increased energy or activity, ✔

three (or more) of the following symptoms (four if the mood is only irritable) are

present to a significant degree and represent a noticeable change from usual

behavior.

1. Inflated self-esteem or grandiosity.

2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).

3. More talkative than usual or pressure to keep talking.

4. Flight of ideas or subjective experience that thoughts are racing.

5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant

external stimuli), as reported for observed.

6. Increase in goal-directed activity (either socially, at work or school, or

sexually) or psychomotor agitation (i.e., purposeless non-goal directed

activity).

7. Excessive involvement in activities that have a high potential for painful

consequences (e.g. Engaging in unrestrained buying sprees, sexual

indiscretions, or foolish business investments).

C. Mood disturbance is sufficiently severe to cause marked impairment in ✔

social or occupational functioning or to necessitate hospitalizations to prevent

harm to self or others, or there are psychotic features.

D. The episode is not attributable to the psychological effects of a substance ✔

(e.g., a drug abuse, a medication or there are psychotic features).

Differential Diagnosis:

1. Schizoaffective Disorder

(insert here)

DSM-5 DIAGNOSTIC CRITERIA FOR SCHIZOAFFECTIVE DISORDER RULE IN RULE

OUT

A. An uninterrupted period of illness during which there is a major mood

episode (major depressive or manic) concurrent with Criterion A of

schizophrenia.

Note: The major depressive episode must include Criterion A1 :

Depressed mood.

B. Delusions or hallucinations for 2 or more weeks in the absence of a ✓

major mood episode (depressive or manic) during the lifetime duration of

the illness.

C. Symptoms that meet criteria for a major mood episode are present for ✓

the majority of the total duration of the active and residual portions of the

illness.

D. The disturbance is not attributable to the effects of a substance (e.g., ✓

a drug of abuse, a medication) or another medical condition.

2. Schizophrenia

DSM-5 DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA Rule In Rule

Out
A. Two or more of the following, each present for a significant portion of

time during a 1-month period (or less if successfully treated). At least one

of these must be (1), (2), or (3):

1. Delusions ✓

2. Hallucinations

3. Disorganized Speech

4. Grossly disorganized or catatonic behavior.

5. Negative symptoms(i.e., diminished emotional expression or

avolition).

B. For a significant portion of the time since the onset of the disturbance, ✓

level of functioning in one or more major areas, such as work,

interpersonal relations, or self-care, is markedly below the level achieved

prior to the onset (or when the onset is in childhood or adolescence, there

is failure to achieve expected level of interpersonal, academic or

occupational functioning.

C. Continuous signs of the disturbance persist for at least 6 months. This ✓

6-months period must include at least 1 month of symptoms (or less if

successfully treated) that meet Criteria A (i.e, active-phase symptoms) and

may include periods of prodromal or residual symptoms. During these

prodromal or residual periods, the signs of disturbance may be manifested

by only negative symptoms or by two or more symptoms listed in Criteria A

present in an attenuated form (e.g, odd beliefs, unusual perceptual

experiences).
 D. Schizoaffective disorder and depressive or bipolar disorder with ✓

psychotic features have been ruled out because either 1) no major

depressive symptoms or manic episodes have occurred concurrently with

the active-phase symptoms, or 2) if mood episodes have occurred during

the active-phase symptoms, they have been present for a minority of the

total duration of the active and residual periods of the illness.

E. The disturbance is not attributable to the physiological effects of a ✓

substance (e.g., a drug of abuse, a medication) or another medical

condition.

F. If there is a history of autism spectrum disorder or a communication ✓

disorder of childhood onset, additional diagnosis is made only if prominent

delusions or hallucinations, in addition to the other required symptoms of

schizophrenia, are also present for at least 1 month or (or less if

successfully treated).

3. MDD with Psychotic Features with Peripartum onset

DSM-5 Criteria for Major Depressive Disorder Rule Rule Out

In

A. Five (or more) of the following symptoms have been present during the

same 2-week period and represent a change from previous functioning; at

least one of the symptoms is either (1) depressed mood or (2) loss of

interest or pleasure. Note: Do not include symptoms that are clearly

attributable to another medical condition.

1. Depressed mood most of the day, nearly every day, as indicated by

either subjective report (e.g., feels sad, empty, hopeless) or observation ✓

made by others (e.g., appears tearful). (Note: In children and adolescents,

can be irritable mood.)

2. Markedly diminished interest or pleasure in all, or almost all, activities ✓

most of the day, nearly every day (as indicated by either subjective account

or observation)

3. Significant weight loss when not dieting or weight fain (e.g., change or

more than 5% of body weight in a month), or decrease or increase in

appetite nearly every day. (Note: In children, consider failure to make

expected weight gain)

4. Insomnia or hypersomnia nearly every day. ✓

5. Psychomotor agitation or retardation nearly every day (observable by

other, not merely subjective feelings or restlessness or being slowed down)

6. Fatigue or loss of energy nearly every day. ✓

7. Feelings of worthlessness or excessive or inappropriate guilt (which

may be delusional) nearly every day (not merely self-reproach or guilt about

being sick)

8. Diminished ability to think or concentrate, or indecisiveness, nearly ✓

every day (either by subjective account or as observed by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal

ideation without a specific plan, or a suicide attempt or a specific plan for

committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, ✓

occupational, or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance

or to another medical condition.

Note: Criteria A to C represent a major depressive episode.

Note: Responses to a significant loss (e.g., bereavement, financial ruin,

losses from a natural disaster, a serious medical illness or disability) may ✓

include the feelings of intense sadness, rumination about the loss, insomnia,

poor appetite, and weight loss noted in Criterion A, which may resemble a

depressive episode. Although such symptoms may be understandable or

considered appropriate to the loss, the presence of a major depressive

episode in addition to the normal response to a significant loss should also

be considered. This decision inevitably requires the exercise of clinical

judgment based on the individual's history and the cultural norms for the

expression of distress in the context of loss.

D. The occurrence of the major depressive episode is not better explained

by schizoaffective disorder, schizophrenia, schizophreniform disorder, ✓

delusional disorder, or other specified and unspecified schizophrenia

spectrum and other psychotic disorders.

E. There has never been a manic episode or a hypomanic episode. Note:

This exclusion does not apply if all of the manic-like or hypomanic-like ✓

episodes are substance-induced or are attributable to the physiological

effects of another medical condition.